RHC Billing Guide - JE Part A
RHC Billing Guide
RHC Provider Number Ranges
Third - Sixth digits:
- 3400-3499
- 3800-3974
- 3975-3999
- 8500-8999
A provider-based CMS Certification Number (CCN) is not an indication that the RHC has a provider-based determination for purposes of an exception to the payment limit.
- 0711 - Admit to discharge
- 0717 - Adjustment
- 0718 - Cancel
- 0710 - No payment
Billable Visit
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 100
CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 110.1
Face-to-face encounter between the patient and a physician, physician assistance (PA), nurse practitioner (NP), certified nurse midwife (CNM), clinical psychologist (CP), clinical social worker (CSW) or in limited situation a visiting nurse (VN) during which a RHC service is rendered.
RHCs can bill for a face-to-face, medically necessary visit furnished by a dentist, podiatrist, optometrist, or chiropractor if the service furnished is on the list of qualifying visits for the RHC and all other staffing requirements are met. All services furnished must be within the state scope of practice for the practitioner and all HCPCS codes must reflect the actual services that were furnished.
RHC Practitioners and Staffing
CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 10.1 and 30.1
- Physicians
- NP
- PA
- CNM
- CP
- CSW
- Register professional nurse (RN) - homebound services
- Licensed professional nurse (LPN) - homebound services
NP, PA or CNM must work in the clinic at least 50 percent of the time the RHC is open. One practitioner must be present in the RHC and available at all times to furnish patient care.
RHC Revenue Codes
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 50
RHC services must be billed with the below RHC revenue codes and a Healthcare Current Procedural Coding System (HCPCS) code descripting the encounter:
- 0521 - Clinic Visit by member to RHC
- 0522 - Home visit by RHC practitioner
- 0524 - Visit by RHC practitioner to a member in a covered Part A stay at a Skilled Nursing Facility (SNF)
- 0525 - Visit by RHC practitioner to a member in a SNF (not in a covered Part A stay) or NF or ICF MR or other residential facility
- 0527 - RHC Visiting Nurse Service(s) to a member's home when in a Home Health Shortage Area
- 0523 - Visit by RHC practitioner to other non RHC site (e.g., scene of accident)
- 0900 - Behavioral Health Treatments/Services
Non-allowed Revenue Codes
Effective April 1, 2016, RHCs including RHCs exempt from electronic reporting under §424.32 (d)(3), are required to submit HCPCS and revenue codes. These revenue codes are not allowed.
- 002x-024x
- 029x
- 045x
- 054x
- 056x
- 060x
- 065x
- 067x-072x
- 080x-088x
- 093x
- 096x-310x
Mental Health Services
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 60
CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 170
Revenue code 0900
Subject to Outpatient Mental Health Limitation which was phased out in 2014
- 2013 - Limitation is 81.25% of Medicare approved amount for service (Medicare pays 65% and patient pays 35%)
- 2014 onward - the limitation is 100% of Medicare approved amount for service (Medicare pays 80% and patient pays 20%)
The mental health treatment limitation amount is applied before application of the coinsurance.
Effective April 1, 2016, report appropriate HCPCS code for each qualifying mental health service.
Services must be within the practitioners' state scope of practice.
- Physicians' services, including services and supplies incidental to a physician services
- NPs, PAs, and CNMs, including services and supplies incidental the NPs, PA and CNMs services
- CP and CSW services, including services and supplies incidental to the CPs and CSWs services
- Transitional Care Management (TCM) effective January 1, 2013
- Chronic Care Management (CCM) - effective January 1, 2016
- Advanced Care Planning - effective January 1, 2016
- Mental Health services
- Physical and Occupational Therapy
- Visiting nursing services
- Telehealth services - originating site
- Preventive Health Services
- United States Preventive Services Task Force (USPSTF) grade A or B
Advanced Care Planning (ACP)
Effective January 1, 2016, ACP is considered a face-to-face service between a practitioner and a patient on advance directives and it is a stand-alone billable RHC visit.
- Coinsurance and deductible applies and will be based on the charges reported on the revenue code 052x service line with modifier CG.
If an ACP is rendered as element of the AWV it is included in the AIR.
- Coinsurance and deductible will be waived
ACP can be billed with another billable visit on the same date of service
- Coinsurance and deductible applies and will be based on the charges reported on the revenue code 052x and/or 0900 service line with modifier CG.
- CPT 99497 - First 30 minutes
- CPT 99498 - Second 30 minutes
Chronic Care Management (CCM)
CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 230.2
Effective January 1, 2016, CCM is a billable RHC service. CMS waived face-to-face requirement for CCM.
- Payment based on Medicare Physician Fee Schedule (MPFS) national average non-facility rate for CPT 99490
- Can be billed with another billable visit on same date of service
- Cannot be billed in conjunction with a TCM service
- Coinsurance and deductible apply
Transitional Care Management (TCM)
CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter, 13 Section 230.1
- Can be billed as an encounter if it is only service provided on day
- If occurs on same date as another visit, only one encounter is allowed
- Only one TCM visit paid and allowed for a 30-day post discharge period
- Must be furnished within 30 days of date of discharge from hospital (including outpatient observation), SNF or Community Mental Health Center
- Direct contact, telephone or electronic communication with patient/caregiver must begin within two business days of discharge
- Face-to-face visits must occur within seven days of discharge for high complexity decision making (CPT code 99496) or within 14 days of discharge for moderate complexity decision making (CPT code 99495)
- Coinsurance and deductible apply
Telehealth Services
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 80
Telemedicine is a non-RHC service; however, RHCs are allowed to bill the originating site facility fee.
- Can be billed when it is only encounter listed on claim
- Revenue code 0780
- HCPCS code Q3014
Visiting Nurse Services
CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 190
Visiting Nurse Services performed by RN or LPN when a patient is considered homebound. Beginning with dates of service on/after April 1, 2016
- Line item date of service
- Type of bill (TOB) 071X
- Revenue code 052X
- Modifier CG
- HCPCS code G0490
- Paid all-inclusive rate (AIR)
Preventive Services
CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 220.1
Influenza (G0008) and Pneumococcal Vaccines (G0009)
- Influenza and pneumococcal vaccines and their administration are paid at 100 percent of reasonable cost through cost report
- Report charges on cost report Worksheet M-4 (Provider-based RHCs) or B-1 (Freestanding RHCs)
- Do not report on UB-04
- Coinsurance is waived
Hepatitis B Vaccine (G0010)
- Hepatitis B vaccine and its administration is included in RHC visit
- Not separately billable. Vaccine and administration can be included in line item for otherwise qualifying visit
- Coinsurance and deductible applies and will be based on the charges reported on the revenue code 052x and/or 0900 service line with modifier CG.
IPPE (G0402)
- IPPE is a one-time exam that must occur within 12 months following beneficiary's enrollment
- IPPE can be billed as a stand-alone visit if it is only medical service provided
- Coinsurance and deductible are waived
AWV (G0438 and G0439)
- AWV is personalized prevention plan for beneficiaries not within first 12 months of their first Part B coverage period and have not received an IPPE or AWV within past 12 months
- AWV can be billed as a stand-alone if it is only medical service provided
- Not separately billable if furnished on same day as another medical visit
- Coinsurance and deductible are waived
Diabetes Counseling and Medical Nutrition
- Diabetes counseling and medical nutrition service provided by a registered dietician or nutritional professional may be considered incident to a visit provided all applicable conditions are met
- Report charges on cost report
- Do not report DSMT (G0108) and MNT (G0270) on UB-04 as a billable visit
- Not separately payable
Screening Pelvic and Clinical Breast Exam (G0101)
- Can be billed as a stand-alone if it is only medical service provided
- Not separately billable if furnished on same day as another medical visit
- Coinsurance and deductible are waived
Screening Papanicolaou Smear (Q0091)
- Can be billed as a stand-alone if it is only medical service provided
- Not separately billable if furnished on same day as another medical visit
- Coinsurance and deductible are waived
Prostate Cancer Screening (G0102)
- Can be billed as a stand-alone if it is only medical service provided
- Not separately billable if furnished on same day as another medical visit
- Coinsurance and deductible apply and will be based on the charges reported on the revenue code 052x and/or 0900 service line with modifier CG
Glaucoma Screening (G0117 and G0118)
- Can be billed as a stand-alone if it is only medical service provided
- Not separately billable if furnished on same day as another medical visit
- Coinsurance and deductible apply and will be based on the charges reported on the revenue code 052x and/or 0900 service line with modifier CG
Lung Cancer Screening Using Low Dose Computed Tomography (LDCT) (G0296)
- Can be billed as a stand-alone if it is only medical service provided
- Coinsurance and deductible are waived. Policy requirements for LDCT can be found in CR9246
HCPCS codes for All Inclusive Rate (AIR) Reimbursement
- Report appropriate HCPCS code for each service line. Include revenue code and other required billing codes
- HCPCS 36415 - venipuncture is included in AIR
HCPCS Codes for Qualifying Visits
- An encounter must include one of services listed under RHC Qualifying Visit List (RHC QVL) (8-1-16)
- Not an all-inclusive list
- All of conditions for coverage and payment must be met for payment to be made
- Stand-alone billable visits for services on/after April 1, 2016 listed in black
- Stand-alone billable visits for services on/after October 1, 2016 listed in red
Payment Type
CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Sections 70.1, 70.2
Medicare pays 80% of RHC AIR, subject to a payment limit, for medically-necessary medical and qualified preventive, per face-to-face visits
- Services incident to a RHC professional service are included in per-visit payment
- Rate does not include services that are not defined as RHC services
- Incident to services may be included on RHC cost report
- CY 2016 Payment limit $81.32
- CY 2017 Payment limit $82.30
Provider based RHCs with less than 50 beds are eligible to receive an exception to the per visit payment limit.
Incident to Services and Supplies
CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 120
"Incident to" refers to services and supplies that are an integral, though incidental, part of service and are:
- Commonly rendered without charge or included in RHC bill
- Commonly furnished in an outpatient clinic setting
- Furnished under physician's direct supervision
- Furnished by a member of RHC staff
"Incident to" services and supplies include:
- Drugs and biologicals that are not usually self-administered, and Medicare-covered preventive injectable drugs (e.g., influenza, pneumococcal)
- Venipuncture
- Bandages, gauze, oxygen and other supplies
- Physical Therapy, Occupational Therapy
- Furnished by a RHC practitioner acting within their state scope of practice
- Assistance by auxiliary personnel such as a nurse, medical assistant, or anyone acting under supervision of physician
Incident to services provided on a different day as the billable visit may be included in the charges for the visit if furnished in a medically appropriate timeframe.
Frequency of Billing - Multiple Visits on Same Day
CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 40.3
Per encounter date of service.
- When multiple encounters occur on same date of service,
- Subsequent to first visit; provided at separate times of day; requires a valid HCPCS
- One claim is submitted with added diagnosis or treatment
- Append modifier 59 to attest conditions are unrelated
- When a medical visit and mental health visit occur on same day
- Two billable visits
- When IPPE and separate medical and/or mental health visit occur on same day
- Two or three billable visits
Beginning October 1, 2016, report modifier CG on one revenue code 052X and/or 0900 service line to receive AIR and charges are subject to coinsurance and deductible.
Non-RHC Service
CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 60.1
The items below are not RHC services and are paid according to Medicare benefit provisions for each type of service.
- Ambulance
- Body Braces
- Durable medical equipment
- Group services
- Hospice services
- Laboratory services
- Practitioner services at certain other Medicare facilities
- Inpatients, outpatient hospital, ambulatory surgical center, Comprehensive Outpatient Rehabilitation Facility (CORF)
- Prosthetic devices
- Routine services, dental care, hearing tests, physical check-ups
- Technical components
- Hepatitis C Screening (G0472)
- Telehealth distant-site fee
Technical Services
CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 60.1
Bill technical components for diagnostic tests (x-rays and EKGs) separately as follows:
- Technical services/components of professional services for provider-based RHCs
- Bill under parent provider to AB MAC(A)
- Submit on UB-04 or 837I
- Technical services/components of professional services
- Bill under independent RHC to AB MAC(B)
- Submit claim on CMS Form-1500 or 837P
Laboratory Services
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 60.1
- Venipuncture is included in AIR and is not separately billable
- Laboratory services are not an RHC benefit and not included in AIR
- Provider-based RHCs bill under parent provider to on UB-04 or 837I equivalent
- Independent RHCs submit claim on CMS-1500 Claim Form or 837P equivalent
Global Billing
CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Section 40.4
- Procedures are included in AIR if associated with a qualified visit and provided in RHC
- RHC must determine if services are within a global surgical period; when RHC furnishes service to a patient that has had surgery elsewhere
Medicare global billing requirements do not apply to RHCs, global billing codes are not billable or reimbursed.
Beneficiary Coinsurance
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Sections 40.2
- 20 percent of all-inclusive rate (AIR) after applicable Part B deductible
- Provider based RHCs billing non-RHC services; coinsurance is applicable to parent provider type and type of service
- Independent RHCs billing non-RHC services; coinsurance is based on 20 percent of allowed amount
Medicare Part B deductible is subject to change annually
Not applicable for certain preventive services - effective January 1, 2011
